A Guide to the Clinical Gynecological Examination

PowerPoint Presentation: A Guide to the Clinical Gynecological Examination Instructed by a Female Guiding Patient Developed by: Cheryl Eden, Petra Ehlert, Joy Lynne Erickson, Scott George, Myranda Stephens and Aimee Yap
PowerPoint Presentation: CLINICAL SKILLS USA , Inc. provides trained instructors as Gynecological Teaching Associates and Male Urogenital Teaching Associates , who share their own bodies for the clinical instruction of the female breast and pelvic, and the male urogenital and rectal exams. Serving medical and nursing schools throughout the U.S.
: To teach competence in clinical pelvic and breast exam technique. ♀ To facilitate the application of “patient-centered” clinical skills and “patient empowerment”. ♀ To enhance proper communication techniques, supporting patient self-disclosure and promoting patient education. ♀ To improve competence in reducing patient anxiety and minimizing patient discomfort. ♀ To facilitate effective learning by reducing student anxiety associated with the invasive exams . GYN Exam Instructional Objectives
PowerPoint Presentation: Why pelvic exams ? ♀ To evaluate the size and position of the vagina, cervix, uterus, fallopian tubes, and ovaries. ♀ Preventive health care for all adult women. (early detection of cancers, infections, STD’s , or other reproductive system problems) ♀ Conducted before prescribing a method of birth control. ♀ Annual pelvic exams are recommended for all women at age 21, or earlier if they become sexually active. Introducing the GYN exam
PowerPoint Presentation: When should pelvic exams be performed? ♀ The American College of Obstetricians and Gynecologists recommends that a young woman participate in her first GYN visit between the ages of 13 and 15, to become familiar with her clinician and to discuss the future gynecologic exam. Regular pelvic exams should begin as soon as a woman becomes sexually active, or by age 21. ♀ Clinical breast exams are recommended every 3 years for women age 20-39 and every year starting at age 40. Mammograms should be performed annually starting at age 40. ♀ Self -breast exams recommended monthly, starting at age 20. Introducing the GYN exam
Patient Anxiety: Patient Anxiety “ Many women suffer tremendous anxiety about their annual gynecological exam. The anxiety is preventing women from receiving the best care possible, and many women who seek care regularly are not pleased with their visits”. Marifran Mattson, Associate Professor of Health Communications at Purdue University Reasons women gave for their fear and anxiety about their annual gynecological exams: ♀ Feelings of discomfort ♀ Embarrassment ♀ Personal intrusion ♀ Fear of finding a problem ( e.g . cancer)
Preparing the patient for the exam: Preparing the patient for the exam Before the exam commences : ♀ Conduct reproductive and sexual history . ♀ Ask patient about past experience with the exam (if any). Address any anxiety. ♀ Explain importance of Pap smears and mammograms, the procedures, and the frequency of the procedures . ♀ Describe basic female reproductive anatomy . ♀ Explain medical jargon that you may be using, such as “palpate” . ♀ Provide preliminary information about the exam procedures. Explain what you’ll be doing, why, and how much time it should take . ♀ Reassure the patient that they will feel “pressure” (not “discomfort” ) during the exam, “It should not be painful. But , please let me know if you do feel any discomfort. ” ♀ Demystify the speculum by demonstrating what it’s for and how it works. Forewarn her of the “clicking” sound ( with the plastic speculum) . ♀ Inform the patient that she may ask to have the exam stopped at any time . ♀ Invite questions at any time.
Reproductive and Sexual History: Reproductive and Sexual History Ask the patient: ♀ Reason for their visit . ♀ History of last clinical exam, pap smear and mammogram. Results? Breast self-exams ? ♀ History of previous medical problems, or menstrual issues. Any abnormal pap smears ? ♀ Menstrual history. Age of menarche. Timing and frequency of menstrual cycles. Last cycle. Extent of flow (number of pads/tampons). Cramping or any other unusual characteristics associated with menstruation . ♀ Total number of pregnancies? No. of live births? Abortions? Miscarriages?
Reproductive and Sexual History- continued: Reproductive and Sexual History- continued Ask the patient: ♀ Are you sexually active? ♀ Age of first sexual intercourse. ♀ Type of sexual activity. Vaginal, anal, and/or oral? ♀ Sexual partners. Male, Female, or both? ♀ Frequency of sexual activity. Most recent sexual encounter. ♀ Number of sexual partners. ♀ Type of birth control and protection methods, if any (e.g. contraceptives, condoms, spermicidals ) Frequency of use. ♀ History of STDs or STIs . (Such as: Chlamydia, syphilis, genital warts, herpes, gonorrhea, HPV or HIV )
Proper communication during the GYN exam : Proper communication during the GYN exam Patients will nearly always attach the most painful possible meaning to medical jargon, if they do not know the term e.g. “palpate” sounds like “penetrate”. ♀ You should ask the patient to “ roll her knees out to the side , ” NOT “spread your legs”. ♀ Feet should be placed into “ foot rests ”, NOT “stirrups.” ♀ Refer to parts of the speculum as “ bills ” or “sides” , NOT “ blades.” ♀ Describe the “ folds ” of the labia, NOT the “lips”. ♀ Avoid using medical jargon by “pressing” or “rolling fingertips gently”, NOT “palpate”. ♀ You should describe findings as “ normal ” , “regular” or “healthy”, NOT “everything looks great” or “you look good.” Choose words carefully to avoid sexual connotations or heightening patient anxiety:
Proper “patient-centered” care : Proper “patient-centered” care ♀ Ask about patient comfort at the outset of the exam and periodically thereafter . Adjust the exam table angle to their preference, and make additional pillows available if desired by the patient. ♀ Provide padding for the patient’s feet in the “foot rests”, and assist in placing their feet into the foot rests. ♀ Invite the patient to observe the exam with use of a hand-held mirror. ♀ Visibly warm the speculum (metal) under warm water. ♀ Ask patient periodically about comfort, and remind them to inform you of any unexpected pain or discomfort during the exam.
Eye Contact and Proper Draping: Eye Contact and Proper Draping ♀ Use direct eye contact when addressing the patient before and after the exam, and regularly during the exam to assess nonverbal reactions. Be sensitive to issues of modesty and vulnerability: ♀ Use proper draping technique with minimal exposure. Expose only the areas being immediately examined, e.g. only one breast exposed at a time during palpation.
PowerPoint Presentation: Source: www.breastcancer.org U.S. Breast Cancer Statistics About 1 in 8 U.S. women will develop invasive breast cancer over the course of her lifetime. In 2011, an estimated 230,480 new cases of invasive breast cancer were expected to be diagnosed in women in the U.S. About 39,520 women in the U.S. were expected to die in 2011 from breast cancer, though death rates have been decreasing since 1990— especially in women under 50. These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness . For U.S. women, breast cancer death rates are higher than any other cancer, except lung cancer. Besides skin cancer, breast cancer is the most commonly diagnosed cancer among American women. Just under 30% of cancers in women are breast cancers. In 2011, there were more than 2.6 million breast cancer survivors in the US. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 15% of women who get breast cancer have a family member diagnosed with it. About 85% of breast cancers occur in women who have no family history of breast cancer, due to genetic mutations that happen as a result of the aging process and life in general. The most significant risk factors for breast cancer are gender (being a woman) and aging.
The Mammogram : The Mammogram ♀ First mammogram between 35-40 years old. ♀ After age 40, yearly mammograms there after .
Breast Cancer Statistics : Breast Cancer Statistics Breast cancer rate of occurrence by site UOQ UIQ LOQ LIQ Areola
Female Breast Anatomy : Female Breast Anatomy
Steps of the Breast Exam : Steps of the Breast Exam Step I: Observe both breasts in multiple positions as patient sits upright. Step II: Conduct palpation of tonsillar , cervical, infra- and supra- clavicular , and axillary areas as patient sits upright . (Breast tissue for larger breasted women) Step III: Conduct palpation of the breast, axillary areas, areolas and nipples, with patient in supine position.
PowerPoint Presentation: Tanner Stage Characteristics I Prepubertal ; elevation of the papilla only II Breast buds are noted or palpable, with enlargement of the areola (age 9-13) III Further enlargement of the breast and areola, with no separation of their contours (age 10-14) IV Projection of areola and papilla to form a secondary mound above the level of the breast (age 11-15) V Adult contour breast with projection of papilla only (age 12-17) Assess Adolescent Development -Tanner Stages-
Steps of the breast exam- inspection: Steps of the breast exam- inspection Step I : ♀ Initially observe both breasts as patient sits up and then leans forward. Examine symmetry and other surface abnormalities. ♀ Look for: tenderness, lumps, skin dimpling, retractions, changes in skin color or texture “ orangue ”, breast size, nipple changes or discharge. ♀ While observing, have the patient sit with arms to her sides, hands on hips with shoulders flexed, leaning forward, and arms raised above her head. ♀ You should use direct eye contact when addressing the patient before and after the exam, and regularly during the exam.
Steps of the breast exam- inspection: Arms at side Arms raised Hands on hips with Initially inspect each breast while the patient is sitting: Steps of the breast exam- inspection shoulders flexed
Steps of the breast exam-inspection: ♀ Inspect underside of each breast ♀ Palpate with both hands Inspect each breast for larger breasted women: Steps of the breast exam -inspection
PowerPoint Presentation: ♀ Use the pads of the middle 3 fingers of one hand. ♀ Press downward using a circular motion. ♀ Apply steady pressure, pushing down to the level of the chest wall. ♀ Apply enough pressure to palpate to 3 levels of depth: - Superficial - Medium - Deep (to the level of the chest wall) Palpation technique
: Step II: Steps of the breast exam-palpation While the patient is sitting upright, palpate for lymph nodes in the tonsillary , cervical, infra- and supra- clavicular areas. Examine for enlarged nodes or masses.
: ♀ While the patient is sitting upright, palpate both axillary areas, “Tail of Spence” . ♀ Palpate using middle three fingers while pressing downward with a continuous circular motion. Apply steady pressure, palpating to 3 levels of depth — superficial , medium, deep. ♀ Examine for enlarged nodes or masses. Steps of the breast exam-palpation Step II:
Mammary & Axillary Lymph Nodes : Mammary & Axillary Lymph Nodes
Breast examination patterns : Breast examination patterns Three methods for systematic examination of the breast: Vertical Strips Pattern Radial Spoke Pattern Circular Pattern
Steps of the breast exam- palpation: Steps of the breast exam- palpation Step III : ♀ While the patient is lying supine, palpate for lymph nodes and other masses in each of the axillary areas, breasts, areolas, nipples, and upper chest.
: Patient education during the exam : regular self-exams (BSE) One out of eight American women will be diagnosed with breast cancer ♀ Look for: lumps, skin dimpling, changes in skin color or texture, breast size, nipple change, discharge Teach BSE while conducting the actual exam ♀ Perform breast self-exam (BSE) “once every month” starting at the age of 20. ♀ Conduct in front of mirror. ♀ “BSE includes both looking and feeling”. ♀ Palpate entire breasts and axillary areas. “Cover entire area”. ♀ Use pads of fingers, “not the tips”.
PowerPoint Presentation: Source: www.breastcancer.org U.S. Gynelogical Disease Statistics About 1 in 8 U.S. women will develop invasive breast cancer over the course of her lifetime. In 2011, an estimated 230,480 new cases of invasive breast cancer were expected to be diagnosed in women in the U.S. About 39,520 women in the U.S. were expected to die in 2011 from breast cancer, though death rates have been decreasing since 1990— especially in women under 50. These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness . For U.S. women, breast cancer death rates are higher than any other cancer, except lung cancer. Besides skin cancer, breast cancer is the most commonly diagnosed cancer among American women. Just under 30% of cancers in women are breast cancers. In 2011, there were more than 2.6 million breast cancer survivors in the US. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 15% of women who get breast cancer have a family member diagnosed with it. About 85% of breast cancers occur in women who have no family history of breast cancer, due to genetic mutations that happen as a result of the aging process and life in general. The most significant risk factors for breast cancer are gender (being a woman) and aging.
PowerPoint Presentation: Vulva Mons Pubis Labia Majora & Minora Introitus Urethral Meatus Clitoris Perineum Anus Mons Pubis Groin-Lymph Nodes Bartholins Glands Skenes Glands Cervix & Os Vaginal Walls Cystocele & Rectocele Cervix Uterus Ovaries Bi-manual exam + Rectal exam Steps of the Pelvic Exam I : External inspection II : External palpation III : Internal inspection: Speculum IV : Internal palpation: Bi-Manual Recto -vaginal
PowerPoint Presentation: External inspection - Vulva (pubic, introitus , urethra, clitoris) - Perineum - Anus External palpation - Mons Pubis & Groin (Inguinal Region) - Bartholin’s & Skene’s Gland - Urethra Internal inspection (Vaginal Speculum ) - Vagina - Cervix Internal palpation: Bi-manual exam - Cervix - Uterine body - Ovaries Steps of the Pelvic Exam
Proper exam supplies : Proper exam supplies ♀ A tray of supplies and instruments should be located within the your reach (e.g. speculum, lubricant, Pap supplies, tissues) ♀ A speculum illuminator, or an adjustable “gooseneck” lamp , may be used for lighting during the exam. ♀ Gloves will be worn throughout the pelvic exam. Not for breast exam . ♀ Ask about allergies to latex before using the latex gloves. ♀ Change the gloves anytime that they become contaminated.
PowerPoint Presentation: Position the patient ♀ The patient is in a lithotomy position, supine with legs bent. ♀ Undergarments should be removed and gown worn with opening in front. ♀ You should help the patient to place her heels into the “foot rests” ( preferably padded). ♀ The table may be tilted up or left flat, depending on the patient’s preference. ♀ Offer pillows if they are available. ♀ Ask the patient to slide “her “bottom” to front edge of the exam table.
Position the patient-continued : Position the patient-continued ♀ Ask the patient to slide her buttocks (“bottom”) up against the back of your hand at the front off-center edge of the exam table. Adjust the pillow(s ) accordingly. ♀ I nstruct the patient to relax her legs and to “roll your knees out to the side.” ♀ For the pelvic exam, You should sit on an adjustable stool between the patient’s suspended legs, though you may need to stand for some portions of the procedure. ♀ You should always be in a position that allows you to monitor the patient’s facial expressions--never blocked from view.
Proper Draping : Proper Draping Be sensitive to issues of modesty and vulnerability ♀ During the pelvic exam you should drape your patient appropriately with a clean cloth or paper drape. ♀ Roll the center of the drape toward the patient, exposing only the physical area to be examined. Hand the rolled drape over to the patient to hold. ♀ The drape should be extended over the thighs and knees, leaving the calves and inner thighs exposed. ♀ Pull drape lower between the knees to aid eye contact. ♀ Ask if your patient would prefer to observe the exam with a mirror, if so, place the drape so that it does not obscure her view.
PowerPoint Presentation: Always forewarn the patient before making initial physical contact on a neutral area, such as the inner thigh. Thereafter, your hands should only make “firm” contact with areas being palpated. Step I: Conduct external inspection and palpation
PowerPoint Presentation: Stage I Pubic hair is very fine. (pre-pubertal) Stage II First signs of pubic hair Growth (age 9-13) Stage III Pubic hair becoming thicker and darker (age 10-14) Stage IV Pubic hair becoming thicker and begins to form the pubic triangle (age 11-15) Stage V Pubic hair growth completes final stage. Adult pubic hair is thick and the pubic triangle is easily recognized. (age 12- 17) Assess Adolescent Development - Tanner Stages
PowerPoint Presentation: ♀ Separate the labia and inspect the labia minora , urethral meatus, clitoris , and vaginal introitus . Step I: Conduct external inspection and palpation ♀ Visually inspect the mons pubis, groin , vulva, perineum, and anus.
External Pelvic Anatomy-Vulva: External Pelvic Anatomy-Vulva
PowerPoint Presentation: Step I: Conduct external inspection and palpation
Bartholin’s & Skene’s Glands: Bartholin’s & Skene’s Glands
PowerPoint Presentation: ♀ Palpate the Bartholin’s glands by inserting index finger into vagina near the posterior end of the introitus . Then pressing firmly between the thumb, make a “U”-shaped continuous palpation of the posterior end of the vagina. Examine for swelling and tenderness. Step I: Conduct external inspection and palpation- continued
PowerPoint Presentation: ♀ Palpate the Skene’s glands by moving index finger and thumb to the anterior end of the vagina. Palpate both sides at the urethral opening. Examine for swelling or tenderness. Step I: Conduct external inspection and palpation- continued
PowerPoint Presentation: Inspect for Cystocele and Rectocele Step I: Conduct external inspection and palpation- continued ♀ Insert index and middle fingers and press downward on peritoneal floor. Ask patient to strain. ♀ Insert index and middle fingers and press upward against anterior vaginal wall. Ask patient to strain. Step I: Conduct external inspection and palpation- continued
Step II: Conduct internal inspection - Vaginal Speculum: Step II: Conduct internal inspection - Vaginal Speculum Warm the metal speculum in advance
Step II: Conduct internal inspection - Vaginal Speculum: Hold the speculum (sized correctly for the woman) at a 45 degree angle. Open labia with opposite hand (1 or 2 fingers) and introduce speculum into vagina away from urethral meatus. Point the tip toward the posterior fornix. Step II: Conduct internal inspection - Vaginal Speculum
Step II: Conduct internal inspection - Vaginal Speculum: Insert bills of speculum gently and slowly along the posterior vaginal wall, pointing downward while depressing the perineal body and rotating at full insertion so that the handle is vertical. Step II: Conduct internal inspection - Vaginal Speculum
: Open speculum slowly, exposing the cervix. Tighten set screw on metal speculum to hold in position. Step II: Conduct internal inspection - Vaginal Speculum
Positioning the speculum - Anteverted v. Retroverted Uterus: Positioning the speculum - Anteverted v. Retroverted Uterus
PowerPoint Presentation: Visually inspect the cervix, os and vaginal walls . Note : ♀ Position - anteverted , retroverted , etc. The position of the cervix offers a clue to the position of the uterus. ♀ Color - should be flesh-colored, ranging from pink to dark brown. Blue or pale color may be symptomatic. ♀ Size and shape of os ♀ C ysts , polyps, erythema bleeding , discharge Step II: Conduct internal inspection - Vaginal Speculum
: Perform a Pap smear as required Step II: Conduct internal inspection - Vaginal Speculum
Pap Smear Supplies: Pap Smear Supplies Spatula Cytobrush
: Insert index and middle finger of gloved lubricated hand into the vagina. Step III: Conduct bi-manual exam
Internal Female Pelvic Anatomy: Internal Female Pelvic Anatomy
: ♀ Palpate the cervix. ♀ Palpate the uterine body between vaginal and abdominal hands. ♀ Attempt to palpate the ovaries with hand on lower abdomen, while vaginal hand pushes upward. ♀ Palpate for masses or tenderness. Step III: Conduct bi-manual exam
Variations in Position of the Uterus : Variations in Position of the Uterus
PowerPoint Presentation: ♀ Conducted to help evaluate the posterior aspect of the uterus (especially if retroverted ) ♀ Allows exam of rectal walls and fecal specimen( initial screen for colorectal cancer or benign polyps) Step III: Recto-Vaginal Exam & DRE
PowerPoint Presentation: Proper Digital Insertion and Exam: 1) Place pad of the middle finger (“anal finger”) on the anus at 45-degree angle. 2) Wait for the sphincter to relax (3 second minimum). 3) Roll the anal finger into rectum slowly while inserting the index finger into the vagina. 4) Palpate the septum between the two inserted fingers. 5) Conduct bi-manual exam. Palpation of cervix, uterus and adnexa . 6) Perform 360-degree sweep of rectum. Examine for masses present on rectal walls. Step III: Recto-Vaginal Exam & DRE 45-degree angle
Normal -vs- Abnormal Findings: Normal - vs - Abnormal Findings Normal : ♀ The uterus, fallopian tubes, and ovaries are normal in size and location. ♀ The uterus can be moved slightly without causing pain. ♀ The vulva, vagina, and cervix appear normal with no signs of infection, inflammation, or other abnormalities . ♀ Bartholin's or Skene's Glands are not swollen, tender, or inflamed. ♀ No masses (nodules) or abnormal tissue are felt in the area between the uterus and rectum ( cul-de-sac) or in the strong bands of tissue (ligaments) that attach to the uterus to hold it in place. ♀ No fibroids are felt during the bimanual pelvic or rectal exams. ♀ No pelvic pain or tenderness is present. ♀ No hardening of tissue ( induration ) is felt.
Normal -vs- Abnormal Findings: Abnormal: ♀ Signs of a sexually transmitted disease (such as genital herpes, genital warts, or syphilis) may be present. Additional testing will be required to determine the cause. ♀ Sores , signs of infection, inflammation, or abnormalities of the vulva, vagina, or cervix are present . ♀ Glands around the vagina ( Bartholin's glands) or urethra ( Skene's glands) are swollen or inflamed . ♀ The uterus cannot be moved (even slightly) during the exam. Pain or tenderness is felt when the uterus is moved slightly or when the area between the uterus and rectum (cul-de-sac) is touched. ♀ The uterus is pushed away from the midline of the abdomen. ♀ The ovaries are painful when touched, enlarged, or not movable (fixed). An ovarian mass is present or an earlier detected mass is still present or has grown larger. ♀ Small masses (nodules) of abnormal tissue are felt near the uterus or in the cul-de-sac. ♀ Uterine fibroids are felt during the bimanual pelvic or rectal exam. ♀ An area of ulceration or a tear is found. ♀ A mass can be felt near one or both ovaries. Normal - vs - Abnormal Findings
Documentation: Documentation Abnormal: ♀ Signs of a sexually transmitted disease (such as genital herpes, genital warts, or syphilis) may be present . Additional testing will be required to determine the cause. ♀ Sores , signs of infection, inflammation, or abnormalities of the vulva, vagina, or cervix are present. ♀ Glands around the vagina ( Bartholin's glands) or urethra ( Skene's glands) are swollen or inflamed. ♀ The uterus cannot be moved (even slightly) during the exam. Pain or tenderness is felt when the uterus is moved slightly or when the area between the uterus and rectum (cul-de-sac) is touched. ♀ The uterus is pushed away from the midline of the abdomen. ♀ The ovaries are painful when touched, enlarged, or not movable (fixed). An ovarian mass is present or an earlier detected mass is still present or has grown larger. ♀ Small masses (nodules) of abnormal tissue are felt near the uterus or in the cul-de-sac. ♀ Uterine fibroids are felt during the bimanual pelvic or rectal exam. ♀ An area of ulceration or a tear is found. ♀ A mass can be felt near one or both ovaries.
PowerPoint Presentation: Date Last Pap G Temp Contraception Age Last MamX P P Meds LMP SBE? AB BP Menses Q X Smoker? Wgt . Resp Allergies  Breasts Symmetrical, Non-tender, no masses, no nipple discharge, no skin changes, no retraction, no axillary , or supra- clavicular lymphadenopathy .  Pelvic External WNL. NL female hair pattern. Urethral meatus normal. Urethra non-tender. Bladder non-tender. Vagina is clean, without discharge/lesion. Cervix smooth, no lesions, no discharge, no CMT. Uterus normal size, shape and contour. Non-tender. . Pelvic support adequate. Adnexa have no masses or tenderness.  Rectal Sphincter tone normal. No hemorrhoids seen or felt. No masses felt. No bleeding. Documentation example of a normal GYN exam
PowerPoint Presentation: Any Questions?